title: Should intentional endovascular stent-graft coverage of the left subclavian artery be preceded by prophylactic revascularisation?
abstract: Thoracic endovascular aortic repair (TEVAR) has emerged as a promising therapeutic alternative to conventional open aortic replacement but it requires suitable proximal and distal landing zones for stent-graft anchoring. Many aortic pathologies affect in the immediate proximity of the left subclavian artery (LSA) limiting the proximal landing zone site without proximal vessel coverage. In patients in whom the distance between the LSA and aortic lesion is too short, extension of the landing zone can be obtained by covering the LSA's origin with the endovascular stent graft (ESG). This manoeuvre has the potential for immediate and delayed neurological and vascular symptoms. Some authors, therefore, propose prophylactic revascularisation of the LSA by transposition or bypass, while others suggest prophylactic revascularisation only under certain conditions, and still others see no requirement for prophylactic revascularisation in anticipation of LSA ostium coverage. In this review about LSA revascularisation in TEVAR patients with coverage of the LSA, we searched the electronic databases MEDLINE and EMBASE historically until the end date of May 2010 with the search terms left subclavian artery, covering, endovascular, revascularisation and thoracic aorta. We have gathered the most complete scientific evidence available used to support the various concepts to deal with this issue. After a review of the current available literature, 23 relevant articles were found, where we have identified and analysed three basic treatment concepts for LSA revascularisation in TEVAR patients (prophylactic, conditional prophylactic and no prophylactic LSA revascularisation). The available evidence supports prophylactic revascularisation of the LSA before ESG LSA coverage when preoperative imaging reveals abnormal supra-aortic vascular anatomy or pathology. We further conclude that elective patients undergoing planned coverage of the LSA during TEVAR should receive prophylactic LSA transposition or LSA-to-left-common-carotid-artery (LCCA) bypass surgery to prevent severe neurological complications, such as paraplegia or brain stem infarction.
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, Medical Centre of the Johannes Gutenberg University of Mainz, Mainz, Germany. weigang@uni-mainz.de
authors.forename: Ernst
authors.initials: E
authors.lastname: Weigang
authors.forename: Jack A T C
authors.initials: JA
authors.lastname: Parker
authors.forename: Martin
authors.initials: M
authors.lastname: Czerny
authors.forename: Lars
authors.initials: L
authors.lastname: Lonn
authors.forename: Robert S
authors.initials: RS
authors.lastname: Bonser
authors.forename: Thierry P
authors.initials: TP
authors.lastname: Carrel
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Mestres
authors.forename: Roberto
authors.initials: R
authors.lastname: Di Bartolomeo
authors.forename: Marc A A M
authors.initials: MA
authors.lastname: Schepens
authors.forename: Jean E
authors.initials: JE
authors.lastname: Bachet
authors.forename: Christian-Friedrich
authors.initials: CF
authors.lastname: Vahl
authors.forename: Martin
authors.initials: M
authors.lastname: Grabenwoger
mesh_terms: D000784:Aortic Dissection / Q000601:surgery; D017545:Aortic Aneurysm, Thoracic / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods*; D057510:Endovascular Procedures / Q000379:methods; D006801:Humans; D015607:Stents; D013348:Subclavian Artery / Q000601:surgery*